Qualitative interview study

Characteristics of the sample

Service users (first-time visitors to PDU) and PDU and referral pathway staff were recruited at all four study sites. Recruitment took place between 4 November 2019 and 27 February 2020 at the SWLSTG, LPFT and SHSCFT sites – roughly coincident with the recruitment period for the WP4 cohort study – and between 17 May 2021 and 1 September 2021 at the BSMHFT site. Follow-up interviews of service users (at all sites except BSMHFT) were conducted between 8 and 10 months post discharge, with the final follow-up interview taking place on 12 November 2020.

Service users

In total, 39 service user participants were recruited across the four sites (see Table 20), 18 of whom were followed up approximately 9 months later (six in each of sites 1–3). Given the low numbers of participants at each site, we identify site by number here and in the analysis that follows to reduce the risk of identifying participants.

Staff

Interviews with a PDU nurse, psychiatrist and unit manager were completed at every site, with an interview with a PDU HCA/support worker at three of the four sites. Interviews with liaison psychiatry staff took place at all sites, with other members of the ED team at two sites. Interviews with other referral pathway staff reflected referral pathways locally. In total, 34 staff participants were recruited (see Table 20).

Thematic analysis

The final coding framework, as applied to the whole qualitative data set, can be found in Appendix 7, Table 54. Thematic analysis of both service user and staff interviews was produced and is presented below, organised by themes and subthemes. For service user interviews, themes follow a roughly chronological journey from ‘arrival’ to ‘discharge, signposting and onward referral’. Themes for staff interviews begin by considering ‘clarity’ around different staff perspectives on the function of PDUs and who the units might work best for, the referral pathway to the PDU, and then the PDU environment and experience of working on the units.

In quotation of data from verbatim transcripts of interviews, single speech marks are used for reported speech or thought and ellipsis for any truncation of data. Where names of people, places or services are anonymised, general terms are given in square brackets. Square brackets are also used for other insertions for clarity. No other annotation is used. Participant identification numbers following quotes indicate site number (as above), role (S = service user; P = PDU staff, R=pathway staff) and identification number and, for service user interviews only, indication of whether the data were collected in the baseline or follow-up interview (B = baseline; F = follow-up). To note, most interviewees, where relevant, used the term accident & emergency (A&E) to refer to the ED. We have not amended this usage in the data.

Service user interviews

Arrival

Being in crisis

Service users entered the PDU disorientated or suicidal. Their crises had often been precipitated by relationship breakdown, family stressors, bereavement, or living in extreme isolation. Often, crises had been exacerbated by self-harm or substance use. Some service users found accessing the PDU straightforward:

I rang the crisis team, told them that I was going to take all my tablets. Then they came and saw me and then took me to the unit.

Most, however, had found asking for and accessing help difficult:

… [the paramedic] said ‘well we’ve been on to the crisis team’ and they basically blanked them. They said ‘well we might get somebody out today’ and they might not. They said ‘well we just can’t leave you at home … the only thing we could do is take you to ED’.

Being sent to the psychiatric decision unit

Most service users were admitted to the PDU through the ED, although a minority arrived directly by ambulance. Experiences of EDs were primarily determined by the quality of communication and levels of connectedness between triage staff, mental health crisis teams and the PDU. At best, service users had been transferred smoothly and directly to the PDU:

Mental health team came down and had a word with me. They spoke to me and they made a decision saying that I wasn’t right and then they said ‘would you come to our decisions unit?’ I said ‘yes, fine’ and I just went along.

However, service users had sometimes been told conflictual or contradictory things, had been passed between several teams or professionals, or had waited for many hours. This had sometimes left them unsure what was happening, struggling to manage the uncertainty, or feeling as though they were a nuisance or a burden on services. On one occasion, this led to inappropriate treatment:

… the nurse in A&E … instructed them to turn me over so they could inject me in the backside but they did it so violently I hit the side rail and that’s how I got bruises on my breast and down my arm.

Impressions

Atmosphere

Many service users described their initial impression of the PDU as of a quiet, calming, soporific place. For those who had previously been treated on noisy and chaotic psychiatric wards, this atmosphere was a pleasant surprise:

It was warm and it was thoughtful, do you want a bit of toast, with no stress. You could lay your head down and there was nobody coming wake you for anything.

For some whose mental health crisis had been precipitated by trauma, this sudden calm could, however, trigger further anxiety:

… when I got there everybody was asleep, so I was like thinking ‘oh God’, creeping about really quietly and then when you got in the chair the chair started creaking and I was like ‘oh God I’m going to wake people up’. So, I didn’t know who the people were, I didn’t know what sort of mood they’d be in.

Service users were particularly struck by the reclining chairs in place of beds. For many, sleeping problems had precipitated their mental health crisis, and for some, being able to catch up on sleep at the PDU proved the most valuable part of their stay. The flexibility which the chairs enabled promoted an atmosphere conducive to sleep:

If you had one of the ordinary beds there it wouldn’t feel comfortable going to sleep in the daytime, you’d feel wrong. They there … you can sleep when you want, it’s … as though they take you out of the real world … all the fear is left on the outside.

It was fine. I think having recliner chairs is probably nicer in a way than having a bed … I feel like if they’d put me in a bed I’d have been like ‘this is an admission’ but having a recliner chair was like ‘OK this is fine’.

However, some service users disliked the chairs:

They need to go … They’re weird. Also, or don’t get rid of them but just put something on top of it when it’s a bed because otherwise you stick to it. The sheets do not stay on the things.

Staff

Service users generally spoke appreciatively of PDU staff, describing them as calm and non-judgemental, and treating them with care and compassion:

She didn’t just say words but she spoke to me in a way that I know without a doubt that she believes that I can move forward, get better and work one day. She’s so kind and loving.

Service users particularly liked the way that staff responded to their distress in very humanising ways, helping them to feel worthwhile and not ‘mad’ or ‘crazy’:

They’re not frightened of anything you tell them. I didn’t see one of them look one bit concerned. They made you feel normal.

Well I think the staff were amazing … It felt like a safe place without and it didn’t stigmatised like oh no what’s wrong with me, am I a crazy person.

Some of the service users had been told that staff were using the CCTV cameras to observe them continually and some had worked this out themselves. Generally, they valued this as an unintrusive way that staff provided them with personal space, especially if they had experienced close observations on psychiatric wards in the past. For some, however, this more ‘hands off’ approach compounded feelings of isolation, hopelessness, or confusion:

Not just leave you in a room and just sit in the office … how does that help? They are sitting in the office and you are like the guinea pig in a cage.

Safety

Feeling safe, feeling unsafe

Most service users reported feeling safe on the PDU. Service users described how the calm and calming atmosphere of the PDU provided them with a sense of containment and security:

I felt safe there [because] I knew I had someone there to talk to in case I got distressed or didn’t feel safe or something, I knew someone was there to speak to. I couldn’t try harming myself there, I couldn’t do it there so I just felt safe.

Sometimes, however, this sense of safety was tempered by service users’ experience of a lack of visible staff presence:

I mean I suppose in a sense I was at least safe in quotes, that I was supposedly being monitored but I was not conscious that an eye was being kept on me in any way. Occasionally but very occasionally, I think like once an hour, someone would just stick their head around the door.

Service users were aware that the safety the PDU offered was limited by the time limits placed on admissions. Those who were feeling suicidal worried that the PDU would not prevent their deaths:

I didn’t feel very safe there as I was suicidal. One chap said to me there, ‘I said I’m going to leave and they [a staff member] said “well leave and just get on with it then”.’.

Several female service users felt unsafe with the presence of male staff and service users in proximity to the female sleeping area:

I suffer with really bad anxiety as well and you’ve got all these people, you don’t know what they’re capable of … you are supposed to feel safe, there’s no privacy at all. I know they’ve got the wall but there’s no privacy.

One male service user affirmed this concern, echoing the women’s requests for more explicitly segregated sleeping facilities:

I think there could have done with some more privacy because the room was off a corridor and there was a glass partition running down the side and there were no curtains up or blinds … they gave me some pyjamas to put on for bedtime and I just got changed in the room and anyone could have been walking past and I’m half undressed.

One woman felt particularly unsafe:

I don’t know what his role was, he was just a staff member maybe a nurse or something, but he just stood there watching Love Island drooling over all these ladies … Having been sexually abused and raped and all kinds of things in my life I’ve got a very strong, very sensitivity to and … it just felt horrible in that room.

Negotiating the balance between freedom and support

Striking the right balance between feeling supported and enjoying daily freedoms could be important to service users’ experience of the unit. This balance seemed to be expressed by both the physical environment and the way the staff ran the unit. Being able to go outside and smoke by themselves could become a welcome symbol of everyday life, in contrast to more traditional experiences of psychiatric care:

[I liked] the fact that I can go out without having a nurse with me. Just go outside and have a fag … I need my freedom. I don’t like having someone around me all the time because it makes me feel trapped, which I can’t really do nothing.

Similarly, service users appreciated the opportunity to take responsibility for their own care, such as preparing food or taking medications while also being checked on by staff:

[Staff member] just meets you where you are at and if you want to go further down the runway, she gently just keeps you where you are now and gives you little nudges forward … OK the first night you are there, ‘yes, I’m going to bring you a glass of water and a tablet. Tomorrow I’m going to say right pop and get yourself some water and I‘ve got your tablets here when you want it’… [Service users] need to be empowered to take the tiniest steps that they can and move forward otherwise you are paralysed, mentally paralysed again.

For those struggling with intense and difficult thoughts, staff awareness and protection was particularly welcome:

We were allowed to go and smoke, we had to give our lighters in and stuff like that. You were monitored and checked on. It wasn’t people in and out, in and out, in and out all the time.

However, some service users found the levels of restriction disempowering:

I didn’t like the fact that you couldn’t just get out whenever you wanted. You had to ask staff. I didn’t like that, I felt as though I was locked in because there were locks on all the doors so you couldn’t get out … I vape and I wanted to go outside to vape and so I had to ask every time I wanted to go outside and then just felt like I was being a nuisance. I mean they didn’t make me feel like that but I didn’t like that aspect about it.

Talking

I could talk to the staff at a deeper level

Service users described the PDU staff as easily approachable and calm, empathic listeners, never shocked or frightened by anything they heard. This meant that many were able to talk to staff at a deeper level than they could with family, friends, or other mental health professionals:

[It was] absolutely fantastic [talking to them]. Just having somebody to listen to you who is not going to judge and understands.

They’re not frightened of anything you tell them. I didn’t see one of them look one bit concerned. They made you feel normal.

I didn’t manage to talk to the staff

Although service users concurred that staff were kind and non-judgemental, they did not necessarily feel able to talk to them:

The staff were lovely, they weren’t nasty or anything. I know one of them just came and asked me you know ‘there’s drinks there if you want a drink or something or you want to eat something there’s biscuits there’. But that’s it. There wasn’t anything like have a conversation.

Some service users found the staff difficult to talk to. In many cases, staff had waited for service users to approach them, and service users had not felt confident in initiating conversation:

it just didn’t seem appropriate, like it didn’t seem like I would say to them this is what’s going on in my head, this is why I’m here … I suppose because they didn’t open that conversation … Like ask me and I will tell you but I’m not just going to sit here and openly say this, this, this and this.

Service users from PDUs with a shorter maximum LOS reported that there was not enough time to enable talking at any depth:

There was an assessment but it was just like they didn’t want to hear anything else they just wanted to hear what happened that day. But it wasn’t only that day that brought me to that situation. It wasn’t just that day it was the whole month … they just cut me off, they just cut me off and just asked what happened that day.

Decisions

It was about more than just the decision-making

Many service users also derived significant benefit simply from the PDU’s calming environment and caring staff. This sometimes became particularly apparent in retrospect, and they used follow-up interviews to identify their PDU as a turning point in their crises:

it gave you a bit of time to just, you felt yourself, you didn’t feel pressured if that makes sense. You didn’t feel you had to be someone else, if that makes sense.

For service users who had previously been treated badly by psychiatric services, the calm, compassion and respect they received at the PDU proved uplifting:

I went in with no expectations but they probably exceeded that by not being horrible to me.

It was the first time I ever received the help I needed

Several service users described having spent many years, and often many decades, making unsuccessful attempts to seek help for their mental health. For some, being offered by the PDU the time and space to explain their needs to staff led to decisions being made which provided them with support they had never previously received:

Well basically [I’d] been neglected [by mental health services] for 20 years… [and the PDU was a] new thing. It’s like doctors, trainee doctors I say that to them and they look more space cadet than me. I don’t know if I‘m mad or is it everybody else that’s mad.

They made their decision without involving me

Service users could describe a very professionalised, staff-led model of decision-making within which they were informed rather than consulted about what would happen to them.

I don’t know, that was just their, what they decided to do … They didn’t give me any options what I wanted to do, I think they just decided [that an inpatient admission] was the best place.

Some struggled with this dearth of participation or involvement in the decision-making process. Whenever they felt as though staff were not listening to or considering the views or needs they expressed, service users could find this undermined their ability to talk in depth with staff:

I was expecting more. I was expecting a proper assessment of what brought you here, what happened, what’s going on, what meds are you on … A) make sure that I am safe, B) ensuring surely the idea of those things is to avoid people coming back into them, right? … Not one person asked me … what can be done to help you not get back there.

Discharge, signposting and onward referral

Discharge went smoothly

For some service users, the discharge process went smoothly:

I think I’m getting all the support I need. I get those two people and as I say hopefully when this lockdown eases my [community psychiatric nurse] will be able to come and see me.

One man, whose precarious living conditions had led to his crisis, described how the PDU had organised him an appointment with emergency housing services and had booked him a hotel to stay in until this appointment. When service users had been able to communicate such detailed challenges and concerns, the PDU could respond with flexibility and creativity.

Discharge overshadowed by lack of connectedness between mental health services

However, the PDU did not always work in such synchrony with the services to which it made referrals. Some service users, though broadly complimentary of the discharge process, were left not understanding what future care they might receive, or from whom:

[The crisis team] came to see me for a bit. There was no, I can’t remember if there was a plan put in place, I can’t remember.

Some service users reported that the PDU had not adequately explained what was happening with their discharge, making it difficult for them to engage with other services:

But on the Monday morning they sort of just put me in a car and said ‘we’re taking you to a local council building’ with a piece of paper and said ‘just go in there’. I wasn’t ready for that … [but] they said they can’t do everything for me and I had to do things myself.

The service user quoted felt so distressed by his confusion and the lack of explanation or support that he subsequently attempted suicide and was then detained under the Mental Health Act.

They discharged me too quickly

Some service users reported that they had not felt safe returning home, with service users sent home from PDUs with a shorter maximum LOS frequently reporting feeling that they their discharges had been overly hasty and insufficiently attentive to their needs, and that they still felt overwhelmed by voice-hearing or suicidal thoughts:

In the morning when they let me go I felt as if they just kicked me out the door … They gave me a leaflet, well a booklet with a few numbers on that I could call which I already knew about. It was ‘OK we’ve done our job now go’ … It wasn’t a nice way of leaving the place.

Some service users at PDUs with a longer maximum LOS also reported this sense of hurriedness. This was particularly problematic for those living alone who were being sent back to a home where equipment that might be used for self-harm or suicide was still spread around. For some, the haste of discharge appeared more about staff attitudes towards them than the duration of their PDU admission:

every time I go in there [to the PDU] I’m left several days before they do anything … they come to me and they go ‘right what would you like us to do, you’ve come to the end of your two days’? I don’t know, that’s why I’m here.

What next?

Most service users had been referred or signposted to the local crisis team or similar community-based services on discharge. Some service users spoke appreciatively of this transition. Nevertheless, many described less satisfactory experiences:

I know when you come out of it there’s hardly any help. So actually you can have the night off being safe and resting but knowing when you come out of it you are back to square one again which is where I am, which is what I did.

Whereas most service users were sent either home or to a crisis house, a minority were transferred to an acute psychiatric ward. These individuals described a diversity of experiences of this. Some felt reassured by the bed and the privacy but others felt unsettled by the abrupt changes to their surroundings:

I don’t know if, I hope I haven’t been sectioned because I don’t know what’s happened with me. I don’t know I think I’m still voluntary or something. But all my body is aching and everything.

In his initial interview (cited above), one service user described his PDU stay as the first mental health support he had been able to access in 20 years. At his follow-up interview several months later, he reported that he still had no consistent or satisfactory care:

No, I’ve got nothing. They [mental health team] came in my house … I said ‘what about [sickness benefits having been stopped due to admin error]’, ‘no, we can’t help you, that’s the dole’. Crisis team don’t know you well enough, that’s it … absolute disaster.

There isn’t the capacity within mental health services

Despite the problematic post-discharge experiences they reported, service users remained largely complimentary about the PDU. Service users attributed the lack of longer-term mental health support the PDU could access for them and the lack of connectedness between services to wider structural, cultural and systemic problems with the mental health system:

I think when you can go somewhere like that I think you are really looked after and they obviously know what they’re doing. I think when you come out of it I think the help and the services are actually shit to be honest.

Signposting and onward referral from the PDU rarely led to service users receiving the longer-term help they needed. For many, the value and effectiveness of the PDU lay not in their referrals or signposting to other services, but in their short-term crisis support. As one service user concluded:

the DU is great but it’s like a sticking plaster on a broken bone.

Staff interviews

Clarity around psychiatric decision unit service

Psychiatric decision unit as a more therapeutic space

All staff agreed that the PDU provided a therapeutic space for service users, perceived as preferable to the busy, chaotic environment of ED:

somewhere to go that isn’t A&E which I’m all for because I hate telling people to go to ED … it’s not a therapeutic environment. So [the PDU is] a therapeutic environment for people with mental health needs in crisis to go somewhere safe away from A&E.

Although there were different understandings of the PDU’s purpose, it was also primarily seen as a space for further assessment and crisis containment which could potentially prevent inpatient admission or further escalation of a crisis:

If they feel after that [ED] assessment that they need a little bit of further assessment because they might not be sure or they might feel that their risk at the moment is still too high to go home they would then refer to PDU.

it’s having people around and having a bit of containment and feeling as if there is somewhere safe to go with people to talk to, they can sit and play cards. It’s that kind of breathing space.

Appreciating the service

On the whole, staff appreciated the role the PDU performed within the crisis pathway. They valued being able to refer into a crisis service where service users could access much-needed care from mental health staff, and where further support in the community could be set up, avoiding risky discharges:

For me … [PDU] assessments are a really valuable service because sometimes patients don’t feel safe to stay at home for various reasons .. the person may need further support and may not need a long-term admission.

Unmet expectations

However, staff did want more functionality from the PDU service. The functionality desired seemed to depend on which service the staff member was located within, as each service had its own priorities and problems. For example, the liaison psychiatry team wanted service users awaiting their Mental Health Act assessment in ED to be able to wait in the calmer PDU environment, although this was outside of the unit’s remit:

it’s about best interests isn’t it, it’s a nicer place and a much calmer place to wait for your Mental Health Act assessment than it is waiting in a busy A&E department.

The psychiatric decision unit cohort

Staff reported that two primary groups of service users seemed to be attending the PDU; service users who had been diagnosed with (or who were likely to meet the criteria for diagnosis of) a personality disorder, and those who had self-harmed, often with the intention of taking their own life:

a lot of the referrals that we do get are people that potentially suffer with personality disorder.

Staff explained that these service users came to the PDU due to the ‘in-between’ nature of the unit. The PDU seemed to provide for a cohort where a hospital admission would be considered too lengthy or restrictive and for whom home discharge was considered too risky:

sometimes people would self-harm or personality disorder, they come very distressed so we offer them, they are not really for admission in a hospital bed … we don’t feel that they are really fit to go home so something in between is the [PDU].

However, there was a query from one staff member over the efficacy of the PDU for service users with personality disorders, suggesting that perhaps this group of service could benefit from a slightly increased LOS:

Sometimes our service users with personality disorders don’t necessarily need an acute inpatient admission and the [PDU] maybe doesn’t provide a lengthy enough time that sometimes meets that individual’s needs … maybe that person needs 72 hours or a little bit longer in hospital than the [PDU] can provide.

In addition, a variety of other crisis triggers were identified which might lead someone to come onto the PDU, such as housing and employment issues, bereavement, difficult family dynamics, and other relationship stressors. More complex cases could involve several precipitating issues and perhaps a mental health diagnosis as well. Other problems could be less predictable, such as people presenting with psychosis presentations, or anxiety practical stressors in response to the COVID-19 pandemic.

Pathway and capacity

Pressure in the pathway

There were multiple pressures on the crisis pathway and a lack of capacity felt throughout the mental health system, in both crisis and community care. While for referral pathway staff the PDU could be perceived as positively easing this pressure, PDU staff discussed the impact of pressure being passed down to the unit, particularly from ED and inpatient wards:

sometimes we’re just forced to take them to be honest . . we don’t actually think this person is suitable but they seem to be pushing it on us quite a lot and I think it’s simply because they’re under pressure as well to get people out of A&E.

It was not always possible to push back on ‘unsuitable’ referrals. These inappropriate referrals could also be seen as linked to the proximity of other services like the 136 suite and, at one site during the pandemic, a temporary mental health ED unit. However, co-location of services could also have the benefit of increasing communication between teams as they spoke face to face more frequently.

The lack of service capacity could be also witnessed in community services. Community teams could have high caseloads, where it was difficult to spend significant one-to-one time with service users, and there was a lack of community resources at one site. Not receiving the right service clearly has a negative impact on service users yet it also detrimentally affects staff working with them, as they described the toll of not providing a good service:

It’s just really shit because you are left either having to … discharge people home or to a family member when people are already highly stressed and unwell. It just doesn’t feel nice, you are not giving a good service, patients are not getting what you think they need.

Communication

Communication was seen as key to the operation of both the PDU and the pathway; for example, being able to communicate the referral criteria of the PDU. However, referral staff sometimes reported the criteria of the PDU as unclear and inconsistent:

I’ve no idea what the criteria is at the moment because whenever we try and agree something, something different comes up.

There were other referral staff who saw the criteria as flexible, and responsive to individual need:

it’s all just case by case … you can be flexible and use it to your patient’s advantage.

Within the PDU, staff largely described open channels of communication. If there were staff disagreements (and these seemed to occur rarely), these were discussed before they escalated. There were also examples of healthy communication between different services. At most sites, staff within liaison psychiatry and the PDU described positive working relationships which were reflected in the ease of referral and ultimately how useful they felt the service was:

I think we tend to have quite a decent relationship with the decisions unit staff … I can’t really say that I’ve had anybody refused that I’ve referred in because … I think that we’ve come to understand what their purpose is a little bit and I’m sure that will change, it’s an evolving service.

Greater communication between services seemed to enable better communication with service users. When staff were more aware of what different parts of the pathway, include the PDU, could do and what they were like, they could then pass this information along to service users.

‘Us versus them’ split between services

An ‘us versus them’ dynamic could emerge between the PDU and other services, as well as a break between other crisis services. At one site, liaison psychiatry felt it was very hard to refer into the PDU but, equally, staff at the PDU felt referrals weren’t always well-considered:

I know that someone had complained to me that they had tried to send someone over to PDU at around 4am a couple of months ago and PDU declined because the person was tired because it was 4am … So, it’s at the point where it’s quite petty and quite difficult.

Sometimes [they] are not [appropriate] … because we have had patients who have been sent to us without telling us that patient is actively withdrawing from alcohol. They came and had a fit on the unit … It’s not fair for the patient either is it.

There was also a perceived split between physical and mental healthcare staff at one ED:

We do work quite closely with them but sometimes it feels like them and us.

This split could have real consequences in terms of service users and staff safety. One PDU staff member spoke about service users who had come to them without their physical needs being met, while another staff member’s own safety had been compromised when information around a service user’s risk profile had not been passed on and they had spent extended time alone with that service user.

Unmet expectations (see Clarity around psychiatric decision unit service) of the unit could feed into this dynamic, as other crisis services perceived the PDU as not addressing their primary concerns. This might be a gap in service provision they thought the PDU should address or feel that the unit had originally been (mis)sold to them. For example, ED staff had been expecting the PDU to take pressure off ED but felt that this had not transpired:

I think sometimes the unit was sold as ‘imagine it’s like an emergency department for patients with mental health’ … But actually . there’s very much of a gatekeeping role that they have about deciding what they will and won’t take.

Responsibility and reward

PDU staff reported that the nurse-led PDU provided them with more responsibility than other roles and this enabled them to develop their skills:

on [PDU] it’s nurse led so you are making that decision about that person’s life, that person’s risk. So, it’s enabled me to build confidence, being able to look at the patient as a whole.

Staff appreciated the holistic approach favoured on the unit where they were interested in ‘the patient as a whole’. This allowed them to address the causes of crisis, such as housing, relationship, or drug and alcohol issues. They were also able to spend long periods of time with each person, which was highly valued, and felt as though they were able to reduce that person’s distress. These ways of working within the unit added to a sense of satisfaction and accomplishment:

I just absolutely love working with patients and one-to-one and … what I quite like about the unit is we give them quite a lot of practical help as well as just talking to them.

However, it was emotionally demanding working with service users in crisis, both due to the acuity of their distress and the lack of formal detaining powers. The latter could leave staff worrying about service user safety. The unit was described by several staff members as a very busy place to work and could be ‘pretty relentless’ (2P01). The difficulty and responsibility of the role could therefore be seen as a double-edged sword; boosting career trajectory but also linked to a high staff turnover at one of the sites:

I think the unit has always had a very high turnover, part of that is due to .. [the PDU] really builds up your skills very quickly and because of that people get into more senior roles very quickly and .. because of the stress and the decision making. I think some people they just find that too much.

Supportive working environment on the psychiatric decision unit

Despite challenges of working on the PDU, such as the emotional demands described above, the overall experience for PDU staff seemed to be that units provided a supportive working environment. The helpful atmosphere on the unit seemed to manifest for staff in two main ways: informal and formal means of accessing support and feeling able to make and challenge decisions. Staff described good working relationships with colleagues and felt able to ask for and offer support on an informal basis:

It’s quite a tight team because we all do this together day in and day out and we are almost each other’s clinical supervisors. We get each other through it. You get a terrible sense of humour because that’s the only way you can make each other laugh sometimes. I feel like we support each other.

There were also a variety of formal support systems in place, such as supervision and reflective spaces.

I have individual clinical supervision usually with one of my seniors from bed management team so somebody at a high level who is much more experienced in this environment.

However, due to the nuances of how reflective spaces were run (with team members of all seniority levels present), staff could feel constrained about how they used those spaces:

I go to reflective practice but I’m trying not to make use of it in a way, I’m trying to be someone who is supporting other people in it.

Staff also felt able to challenge decisions being made, such as whether to accept a referral or the discharge destination of a service user. Even if a decision still stood, the freedom to challenge authority in and of itself was seen as valuable:

when I read through the referral and had my reservations first thing I did was pick up the phone and call the manager and aired my grievances in terms of being made to take this referral. Not thinking it would change anything but just as an opportunity to vent off if you like. But I guess that’s an example of where I feel able … to challenge decisions.

Tensions

Tensions were perceived between the service staff wanted to offer and the service they were required or able to offer. These tensions were often related to time and capacity. The pressure to move service users through ED increased during the COVID-19 pandemic, and units sometimes brought in new measures to assist with this, such as admitting people despite already being at maximum capacity. However, this adaptive response could bring its own issues of feeling ‘almost like a conveyor belt, which is awful to describe it like that’ (SWMDU1, PDU manager). An increase in number of service users on the unit could compromise standards of care, with service users undergoing lengthy waits to be spoken to. Subjecting service users to long wait times or depriving them of adequate time and engagement with staff was experienced as particularly difficult where staff prioritised these elements of their care:

the number one thing that helps is the time and the space. It’s an opportunity to slow things down a bit for them and to help get to a position where they can consider their circumstances with the guidance of staff.

If you can sit down with someone and listen to everything that’s happened and then just go you know what that sounds really shit, I can really get why you are here … I think for a lot of people that’s the first step for them getting better.

Impact of COVID-19

The impact of the COVID-19 pandemic was wide-ranging, for staff, service users and the crisis pathway. Almost all staff agreed that there was an initial lull in presentations and referrals at the start of the first lockdown. This was countered by higher numbers accessing services later on during the pandemic:

So, after the first few weeks that were very, very quiet we then saw a huge influx of much more unwell people than I’ve been used to seeing.

The issues with which service users presented and the cohort of people accessing services also changed. For example, staff reported increased cases of self-harm, domestic abuse, psychosis, the effects of isolation, drug and alcohol issues, loss of employment, and anxiety and depression. Some staff also described seeing more young people and people who were new to mental health services. One staff member summed up the variety in presentations:

There were a lot of issues regarding mental health patients who had been stable up until the lockdown and then that had intensified symptoms that they were dealing with naturally. So everything from people who were well treated and their anxiety and the lockdown and people cooped up in their house had triggered off a response to people who were drinking more heavily with lots of time on their hands, to people losing jobs or relationships.

There were two key changes staff saw as impacting service users. First, a lack of face to face contact (both in terms of service delivery and regular social contact) particularly for service users and people already feeling isolated. Second, the closure of certain services, particularly support groups in the community, although some new services were also developed specifically to address concerns around COVID-19. The crisis pathway was modified in response to the pandemic. Some services were temporarily suspended, and new services were opened, as well as the composition of teams and the way existing services were used both changed. For example, at one site the capacity of the PDU was increased, while at another the PDU closed temporarily and staff were reassigned to other services. In another site a new mental health ED unit was opened which impacted on referrals to the PDU:

It just feels that we are constantly taking referrals from them and constantly having pressure from the bed manager to take people as well. Just quite a lot of pressure at the moment.

For staff themselves, if they had been reassigned to another service this could be experienced as unsettling and high numbers of staff sickness, shielding or isolation could increase staffing pressures:

we couldn’t do the things that we normally do for our well-being so all that it was for us was work and home.